Mike Allen has health insurance through SSI disability and Workers Compensation, but his insurance doesn't cover his wife, Vicki, who needs knee surgery but has been unable to obtain affordable health insurance, / Trevor Jones/CentralOhio.com

Written by

Lisa Bernard-Kuhn

and Russ Zimmer

Five key terms to know

• Exchange: The online exchanges, also known as marketplaces, will serve as the main portal for people and small businesses to compare health insurance plans, costs and find out if they’re eligible for subsidies or other benefits. • Essential health benefits: The set of health care service categories that must be covered by plans offered on exchanges starting in 2014. They must include items and services within these 10 categories: basic doctor or clinic services (also known as ambulatory patient services); emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services, as well as chronic disease management; and pediatric services, including oral and vision care. • Tax credits: People who buy coverage on the exchanges might be eligible for tax credits they can use to lower their monthly premiums. Tax credits will be given to people earning less than 400 percent of the federal poverty level, about $46,000 per year for one person or $94,000 for a family of four. Roughly 916,000 people in Ohio are expected to be eligible for the credits. • “Metal level” or actuarial value: It’s a tough but important term. The health reform law establishes four levels of coverage to be offered on the exchanges. The levels are named for precious metals; the more precious the metal, the more the plan will cover — and the more it will cost. As plans increase in value — bronze at 60 percent of actuarial value, silver at 70 percent, gold at 80 percent and platinum at 90 percent — they would cover a greater share of an enrollee’s medical expenses, although the details could vary across plans. Officials typically point to the “silver” plan as the “average” plan; it’s also the first level where individuals can get a tax credit for buying coverage. • Navigators: Entities that will help inform people and small businesses of their options on the exchange, as well as help with enrollment. Nearly $7 million in federal grant dollars are coming to Ohio and Kentucky to fund the work of navigators. Sources: Kaiser Health News, U.S. Department of Health and Human Services

More resources

Visit www.healthcare.gov for more details on the online insurance marketplaces and additional details about the Patient Protection and Affordable Care Act. A 24-hour consumer hotline is available at 800-318-2596. Spanish-speaking consumers can find the same help at CuidadoDeSalud.gov.

Who gets a subsidy?

For families with incomes below 400 percent of the federal poverty line, tax credits will be available to help offset the costs of mandatory health insurance. Below are some examples of how much help certain households will qualify for, according to a calculator created by the Kaiser Family Health Foundation.

Household

Income in 2014

Maximum tax credit*

25-year-old, single, no children

$25,000

$1,301

35-year-old couple, one child

$40,000

$6,705

45-year-old couple, three children

$60,000

$8,975

55-year-old couple, one child

$75,000

$8,252

*Assumes enrollment in a silver plan, a nonsmoking household and children younger than 21.

More

ADVERTISEMENT

In May 2010, Mike Allen fell off the back of a moving truck while working for a Zanesville food producer. He was pinned by the truck, breaking his leg and crushing his foot. Those injuries required six surgeries during the following three years.

Health insurance through his employer covered his initial treatment and, when the company let him go a year later, he started receiving limited Medicare after he was deemed eligible for disability payments through the U.S. Social Security Administration.

But when Mike, 52, was severed from his employment, his wife, Vicki Allen, 59, lost her coverage, too — only she was not eligible for the assistance available to Mike. With his disability and pension, their monthly income is $300 per month too high to qualify for Medicaid, which cuts off eligibility at $1,300 for couples without a child in the home.

COBRA, a temporary insurance option for laid-off workers and their families, was offered to the couple, Vicki said, but it carried a $900 per month premium.

Vicki had slipped between the cracks — her household didn’t qualify for public health care but couldn’t afford private options.

“The pain I experience affects my day-to-day life considerably and the fear of not being able to find affordable health care quite honestly depresses me,” she said.

“I have osteoporosis and osteoarthritis and I need two total knee replacements,” Vicki said. “So I am going to try (to) buy some insurance during open enrollment in the fall.”

Across America, an Oct. 1 deadline is looming for states and the federal government to launch Web-based health insurance marketplaces and begin enrolling millions of people. The online sites, also called exchanges, will serve as the main way for lower-income people, small businesses and people currently without insurance to compare health insurance plans and costs and find out if they’re eligible for subsidies or other cost-saving benefits.

The marketplaces are a key element of the nation’s health care reform law — the Patient Protection and Affordable Care Act, also known as Obamacare. They are considered essential to helping people meet the requirement that most adults younger than 65 have health insurance starting in 2014.

7 million people could join

For people who have insurance through their employer, the exchanges might not matter much — unless they can’t afford their employer’s insurance offerings. They still can go to the exchange and possibly receive a subsidy.

About 7 million Americans are expected to turn to the exchanges this fall, either because they don’t get health insurance at work or because the coverage is unaffordable. By 2017, that number is expected to climb to 24 million, according to estimates from the Congressional Budget Office.

Less than a month before enrollment kicks off, a little more than half of the public says they don’t have enough information about the law or the marketplaces to understand how they will be affected, according to a national poll released this past week by the Kaiser Family Foundation.

“I think there is still a lot of uncertainly among us, and even the people who are setting up the exchanges, as to how most people are going to access them,” said Dr. Lawrence Holditch, medical director of the Cincinnati Health Department. He attributed the questions to the fact that “the exchanges are not here yet.”

But public awareness is critical to keeping the exchanges affordable — and attracting young, healthy adults to buy new health plans, experts say.

The federal government in April announced plans to spend $54 million to hire nonprofit groups and individual “navigators” to educate and enroll consumers in the federally-run exchanges. Ohio got about $2.26 million.

Obamacare supporters in recent weeks have launched educational campaigns across the country aimed at spreading the word about the marketplaces and the insurance options to be offered on them.

Ohio is among 32 states that have opted to let the federal government run their marketplace.

Exchange details

Under the exchanges, Ohioans will spend about $332, on average, to cover monthly insurance premiums, according to state data. All told, 12 companies have been approved by the state to offer more than 200 plans.

To help enroll people in the exchanges in the coming weeks, Cincinnati’s Health Department expects to hire a full-time “navigator” who will help enroll residents. The department is using about $81,000 in federal money to pay for the position, one they hope to fill by Oct. 1.

Navigators are different from insurance agents because they can’t promote or sell insurance plans. The role has been controversial in Ohio, with some nonprofits arguing they’re left out of serving in the role because of the state’s rules governing them. The navigators must meet conflict of interest and certification rules.

In August, the Ohio Association of Foodbanks was awarded a $1.95 million Federal Navigator Grant, the largest such award in the state. Deputy Director Jason Elchert said the group anticipates having 30 to 40 navigators spread across the state and ready to go on Oct. 1.

“Maybe in my situation — I’m computer savvy, I’m familiar with insurance — I may decide to go to healthcare.gov and just look at what’s available. There may be some folks who need a few questions answered, and they may just want to call the health care call center. But there are a lot of folks with a disability, who are older, or maybe have never had insurance before who may need some extra help,” he said.

Not every health department is sure of what its role will be. The Zanesville-Muskingum County Health Department and the Mansfield/Ontario/Richland County Health Department, for example, said they are unsure what resources they will commit to helping people sign up.

“We are exploring opportunities to assist the community and its residents with enrollment,” said Zanesville-Muskingum Health Commissioner Corey Hamilton in a statement. “But have not made a final determination of our specific role or what resources we can commit to it.”

Ohio also is one of 10 states where Enroll America, a Washington, D.C.-based nonprofit, is targeting outreach efforts with ramped-up education campaigns.

“It’s an overwhelming task, but I’m feeling confident we’ll do a good job getting the word out,” said Trey Daly, the group’s Ohio director.

Other big events in 2014

The coverage sold by private insurers on the marketplaces will go into effect beginning Jan. 1.

Adults younger than 65 without insurance by March will face a federal income tax penalty of at least $95, or 1 percent of their gross annual income. The penalty rises in 2015, and will it hit 2.5 percent of an uninsured person’s income by 2016.

However, having insurance in 2014 will be under the honor system, because the IRS won’t be able to track whether you received health insurance from your employer. That’s because the deadline for requiring most employers to offer coverage, the last key piece of the law to kick in, was pushed back until 2015.

Also on Jan. 1, insurers no longer will be able to exclude people with pre-existing conditions.

More than 100 million Americans have some sort of pre-existing health condition, but it typically is a problem only for people who try to buy individual coverage, several studies have shown.

For insurers, the new requirement is a risk that adds to their costs. A robust pool of exchange buyers is be needed in each state to keep costs low and spread the risk.

“I’m not the first one to wonder if you’re only going to have a bunch of people signing up who are mostly sick — and that’s why education is so important,” said Goddard, of HealthPoint Family Care.

“This is a big test,” he said. “No one knows how it’s going to play out, but we’re in it for the long haul.”